Page 101 - Clinical Pearls in Cardiology

Auscultation of the Precordium 89

But this apparent fixed splitting usually disappears when
the individual assumes the sitting or standing position.
So the diagnosis of fixed splitting should be made only
after careful auscultation of S2 in the upright (i.e. sitting
or standing) position.
7. When do you say that P2 is loud?
The observation of an abnormally loud P2 component
of the second heart sound is almost always indicative
of pulmonary hypertension. P2 is normally inaudible
at the cardiac apex. Therefore, S2 appears to be single
at the apical area in normal persons (i.e. only the A2
component is audible). The occurrence of both the
audible components of S2 (i.e. A2 component and
P2 component) at the apical area is an indication
of increased intensity of the P2 component. In such
conditions, the P2 is said to be loud. (Ref: Synopsis of
cardiac physical diagnosis, Abrams. 2001).
8. What is the significance of S3?
The augmented early diastolic filling of the ventricle
(either due to increased left atrial pressure or due to
increased distensibility of a dilated ventricle) leads to a
vibratory motion of the ventricular walls, valve apparatus
and the inflowing blood mass. This vibratory motion
produces the low pitched S3 sound. It may be normally
heard in young individuals. However, an audible S3 in
an elderly person is always pathological.
The diastolic “pericardial knock” is a particular
form of S3 (loud and high-pitched) due to the sudden
distension of the left ventricle against the calcified
pericardium in constrictive pericarditis.